On Call High BP What Meds To Give

[OR 1]

I need some help

When you're on call- get a call from a nurse for a BP that's say 160/85 or 175/85 with no s/s no blurry vision, chest pain , pullmonary edema, urine output normal, what approach do you take?

Some residents have told me just increase the existing BP med like 25 toprolol to 50
Other residents have said no use hydralazine or vasotec

If no t on any previous BP meds I guess I use hydralazine or vasotec, is that right?
I'm really not sure. please give some suggestions, thanx

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[deleted109597]

Whatever you and your senior are comfortable with.
Metoprolol 5mg IV, Labetolol 5mg IV are what we use. I wouldn't start with anything PO, but enaloprilat may work, if that's what you want. Hydralazine, some places love it, others hate it. They all work in some people, less so in others. Just have a good algorithm and stick with it.
Also, do what your chief says, unless it is borderline (or actual) malpractice to do so.
Now, you can certainly bump their PO meds if this continues to be a problem.

 

[Blade28]

Some residents have told me just increase the existing BP med like 25 toprolol to 50

If you're titrating oral BP meds, you're going to have to wait a while before you see any effect.

 

[souljah1]

For general medicine admits that aren't CAD/CHF related, I usually put call housestaff orders if BP >180/>100. There is no urgency to treat a BP like the ones you mentioned. Despite that, nurses call a bunch. Honestly, if someone doesn't have a cardiovascular or renal disease, who cares about Stage 2 hypertension in the hospital? I look at BP's like that as an outpatient thing. Or, at least up to the discretion of the primary team. I guess if I had to do something about it, I'd uptitrate whatever BP meds they're on AFTER making sure that it isn't due to pain, delirium, stress, withdrawal, etc. The last thing I want to someone hypotensive a few days later b/c I didn't figure out they were undertreated for pain.

For hypertensive urgency (>200/>120) with no symptoms or evidence of end organ damage, I'll uptitrate BP meds if they are already on them. If they are maxed on their current BP meds, I'll add a third. For most of these instances, these folks have been living with BP's like this for a while. You don't want to over do it.

I really don't use any IV antihypertensives unless someone is in hypertensive emergency. I usually use Labetolol in that setting (much better than metop for lowering BP), Nitros, and less often Hydralazine.

 

[pillowhead]

It also just depends on the patient. Are they chronically hypertensive and live at those pressures all thes time? If so, there's really no urgent need to decrease them if they're asymptomatic. Giving IV meds can actually bottom them out (just had an M&M on this exact issue. Remember to treat the patient, not a freaking out nurse or a number.) If they're a TIA or stroke patient, we don't bat an eyelid until SBP>220 or DBP>120. Obviously if someone's post-op or admitted for ACS or ICH, those numbers would be unacceptable. That's what clinical judgement for (I don't mean that in a snarky way. It's tough to figure out what to do sometimes. I just want to make a point that we shouldn't just slam IV meds to make numbers look pretty, that's all.)

 

[Coastie]

Depends on alot of co-morbidities. Depends on the underlying cause.

Recent stroke? Sometimes they like the BP high.

Pre-HD? Better not lower it too much.

Etc, etc, etc etc.

Vasotec is a decent prn. I prefer it over labetalol iv and hydralazine.

I need some help

When you're on call- get a call from a nurse for a BP that's say 160/85 or 175/85 with no s/s no blurry vision, chest pain , pullmonary edema, urine output normal, what approach do you take?

Some residents have told me just increase the existing BP med like 25 toprolol to 50
Other residents have said no use hydralazine or vasotec

If no t on any previous BP meds I guess I use hydralazine or vasotec, is that right?
I'm really not sure. please give some suggestions, thanx

 

[Winged Scapula]

Agree with Tired.

Those are just numbers and not particularly worrisome ones unless you are trying to keep CPP down.

Asymptomatic and those numbers? Leave them alone and rewrite your call orders...

 

[Faebinder]

I play defense.....my limits is 170+ on systolic and 90+ on diastolic.

I'm with McNinja... 5 mg metoprolol IV and if not available then labetalol 5 mg IV.

If they have a contraindication then I would hit them with the Vasotec.

Many of my patients are NPO (obstruction, etc).. so I dont bother with PO pills and yeah it would take a while for PO to kick in and if they are not moving their bowels then it will take forever.

 

[Winged Scapula]

None of the hospitals I worked in allowed IV beta blockers unless the patient was on tele or in the unit. Thus, any such order required ME to come and push it. Not a problem if the patient really needs it, and I generally found that it would work if I gave 15 mg of Metop (divided doses) IV but as Tired notes, some nurses start to freak out or just get pissed because they have to draw up the meds and the flush, track down the portable monitor and stay in the room adn record vitals. They'd just rather I send them to the unit.

 

[Dejavu]

This is coming from an anesthesiologist, so what do we know about medicine outside of the OR/PACU, but those numbers are not particularly high, probably not dangerous. Maybe the guy was just standing up and walking around, maybe he is just plain nervous, maybe he is mad at some commotion in the bed next to him. Who knows. I say get some more numbers before treating.

When deciding between beta blockers and hydralazine, check the heart rate. If it is already low, hydralazine becomes a better option. Otherwise, labetalol works.

As for a particular drug not working for a particular pt, maybe the dose was inadequate.

 

[bluesdude]

I need some help

When you're on call- get a call from a nurse for a BP that's say 160/85 or 175/85 with no s/s no blurry vision, chest pain , pullmonary edema, urine output normal, what approach do you take?

Some residents have told me just increase the existing BP med like 25 toprolol to 50
Other residents have said no use hydralazine or vasotec

If no t on any previous BP meds I guess I use hydralazine or vasotec, is that right?
I'm really not sure. please give some suggestions, thanx

If you have access to uptodate I recommend reading"Management of severe asymptomatic hypertension (hypertensive urgencies".

 

[anamarylee]

The first thing I do is take the BP myself with a manual sphyngomanometer. 95% of the time it's normal, or at most 160/90 which I don't treat if they are asymptomatic. As someone mentioned, if the patient is s/p recent CVA you don't want to lower the BP, in fact you need to keep it up. Had a patient like this with orders to keep MAP above a certain number which the nurses were not "comfortable" with. They notified me when the pressure was adequate for that patient and looked at me funny when I didn't order anything.

The only thing available at 3 am is Vasotec, so I use that. If they are tachycardic as well, then I use metoprolol IV.

 

[Pir8DeacDoc]

I do nothing.

Why do you want to treat a number without symptoms? Sure, you can go in there, wake the poor guy up, shove a bunch of new meds on him in the middle of the night, but what the hell for? You're not making him feel any better, you're making yourself feel better. It is pointless, and there is no benefit.

Completely agree with this.